Cancer Nursing

Cancer Nursing

GENERAL CONSIDERATIONSCancer can be considered a chronic disease requiring ongoing management, rather than a terminal illness. It consists of more than 100 different conditions characterized by uncontrolled growth and spread of abnormal cells. Normal mechanisms of growth and proliferation are disturbed which results in distinctive morphologic alterations of the cell and aberrations in tissue patterns.

Differences Between Malignant and Benign TumorsCHARACTERISTICBENIGN MALIGNANTGrowth Slow, expansive InvasiveDifferentiation Fully differentiatedImmature, poorly differentiatedMetastasis Absent Present

The malignant cell is able to invade the surrounding tissue and regional lymph nodes. Primary cancer usually has a predictable natural history and pattern of spreadMetastasis is the secondary growth of the primary cancer in another organ. The cancer cell migrates through a series of steps to another area of the body. This is the reason that cancer cannot always be cured by surgical removal alone. Most patients die as a result of metastases rather than progression of the primary cancer. Metastasis begins with local invasion followed by detachment of cancer cells that disseminate via the lymphatics and blood vessels and eventually establish a secondary tumor in another area of the body. Lymph nodes are often the first site of distant spread.

How cancer spreads. Cancer cells may invade nearby tissues or metastasize (spread) to other organs. Cancer cells may move to other tissues by any or all of three routes: venous, lymphatic, or seeding.

ETIOLOGY, DETECTION, AND PREVENTIONEpidemiology

Although overall cancer incidence has decreased in the past 5 years, blacks are more likely to develop and die from cancer than any other ethnic group.

Age is the most outstanding risk factor for cancer.o Cancer incidence increases progressively with age.o Approximately 77% of people diagnosed with cancer are over age 55.

80% of all cancers in North America are related to lifestyle habits (ie, smoking, alcohol consumption, diet) and environmental carcinogens.

o Tobacco is a major cause of cancer related deaths. The ACS estimates 180,000 deaths in 2003 will be attributed to tobacco use.

o Excess alcohol intake is associated with cancers of the mouth, larynx, throat, esophagus, and liver, especially when combined with smoking. In addition, regular consumption of alcohol is associated with an increased risk of breast cancer. This may be due to alcohol-induced increases in circulating estrogens.

o Exposure to carcinogens, such as asbestos, benzene, and radiation, increases the risk of developing certain types of cancer.

o Solar ultraviolet radiation exposure is related to an increased risk of skin cancers.

There is a hereditary predisposition to specific forms of cancers that have been linked to certain events within a gene (ie, BRCA1 and BRCA2 in breast cancer).

Infections and viruses are associated with an increased risk of certain forms of cancer.

o Human papilloma virus—cervical cancero Epstein-Barr virus—lymphomao Hepatitis B and C—hepatocellular cancero Helicobacter pylori—may be linked to gastric cancer

Five-year survival rates are increasing with improved therapy and earlier detection.

Ongoing genetic research is searching for the ability to correct and modify hereditary susceptibility.

Patterns of incidence and death rates vary with sex, age, race, and geographic location.

Leading Sites of Cancer Incidence and Death—2003 EstimatesCANCER INCIDENCE BY SITE AND SEX*

CANCER DEATHS BY SITE AND SEX

Male All sites 675,300 All sites 285,900Prostate 220,300 Lung and bronchus 88,400Lung and bronchus91,800 Prostate 28,900Colon and rectum 72,800 Colon and rectum 28,300Urinary bladder 8,600 Pancreas 14,900Melanoma of the skin 29,900 Non-Hodgkin's lymphoma 12,200Non-Hodgkin's lymphoma 28,300 Leukemia 12,100Kidney 19,500 Esophagus 9,900Oral cavity 18,200 Liver 9,400Leukemia 17,900 Urinary bladder 42,200Pancreas 14,900 Kidney 7,400Female All sites 658,800 All sites 270,600Breast 211,300 Lung and bronchus 68,800Lung and bronchus 80,100 Breast 39,800Colon and rectum 74,800 Colon and rectum 28,800Uterine 40,100 Pancreas 15,300Ovary 25,400 Ovary 14,300Non-Hodgkin's lymphoma 25,100 Non-Hodgkin's lymphoma 11,200Melanoma of the skin 24,300 Leukemia 9,800Thyroid 16,300 Uterine 6,800Pancreas 15,800 Brain 5,800Urinary bladder 15,200 Multiple myeloma 5,500* Excluding basal and squamous cell skin cancer and carcinoma in situAmerican Cancer Society, 2003

Nutrition, Physical Activity, and Cancer Diet does influence the risk of cancer. Among non-smokers, dietary choices and

physical activity are the most important modifiable risk of cancer. The ACS established guidelines on nutrition and physical activity in 2001.

These recommendations are consistent with the 2000 Dietary Guidelines for Americans

o Use the Food Pyramid as a guideline and eat a variety of foods with an emphasis on plant resources.

o Eat five or more servings of vegetables and fruit daily.o Choose whole grains over refined grains.o Limit consumption of red meats, especially high-fat and processed meats.o Maintain a healthful weight with BMI (Body Mass Index) between 18 and

25 (see page 721).o Limit alcoholic beverages to no more than 2 drinks per day for men and 1

drink per day for women. ACS recommendations on physical activity:

o Adults should engage in at least moderate activity for 30 minutes or more 5 or more days of the week: 45 minutes or more of moderate to vigorous activity 5 or more days per week may reduce breast and colon cancer.

o Children and adolescents should engage in 60 minutes per day of moderate to vigorous physical activity at least 5 days per week.

Detection and PreventionPrimary prevention and secondary prevention are effective measures in decreasing mortality and morbidity of many cancers. Most cancers, however, are diagnosed after reported symptoms. The ACS recommends specific primary and secondary prevention measures to reduce an individual's risk of cancer death.

Recommendations for the Early Detection of Cancer in Asymptomatic PersonsCANCER SITE TEST AGE +14Skin Skin assessment 20-39 Every 3 years

> 40 AnnuallyColon and rectum

Fecal occult blood test (FOBT)orFlexible sigmoidoscopyorFOBT and flexible sigmoidoscopyorDouble-contrast barium enemaorColonoscopy

Men and women age 50+

Annually


Every 5 years


Annual FOBT and flex sigmoidoscopy every 5 years


Every 5 years

Cervix Screening should begin approximately 3 years after a woman begins having intercourse, but no later than age 21. Screening should consist of annual pelvic examination with Pap test. At age 30, women who have had three consecutive normal results may get screened every 2 to 3 years. At age 70, women who have had 3 normal tests over 10 years may choose to stop screening. Screening after total hysterectomy is not necessary unless the surgery was done for the treatment of cervical cancer.

Onset of sexual activity or age 18

Annual; may become less frequent after age 30 (see second column)

Mouth Oral examination 20-39 Every 3 years40+ Annual

Prostate PSA and digital rectal examination 50 AnnualBreast Breast self-examination Women

age 20+Monthly

Clinical breast examination Ages 20-39

Every 3 years

Mammography Age 40+ Annual

Testicular Self-examination Age 15-35 Annual

Uterus All women should be educated to report abnormal vaginal bleeding. Women with a history of hereditary nonpolyposis colon cancer should be offered annual endometrial biopsy beginning at age 35.

American Cancer Society, 2004.

Primary PreventionThe assessment or reduction of risk factors before the disease occurs:

Make appropriate lifestyle changes. Stop smoking. Limit alcohol intake. Eat a healthy diet as outlined above. Be physically active: maintain a healthy weight and follow exercise guidelines

outlined above. Avoid sun exposure, especially during the hours of 10 A.M. and 4 P.M. and cover

exposed skin with sunscreen with a skin protection factor (SPF) of 15 or higher. Those at high risk for certain cancers should consider genetic counseling and

testing. Chemoprevention.

o Aspirin—low-dose aspirin may reduce risk of breast cancer and colon polyps.

o Tamoxifen—can reduce the risk of breast cancer in women who are at high risk by nearly 50%.

o Finasteride—reduces risk of prostate cancer.o COX-2 inhibitors — reduce risk of colorectal cancer in high-risk patients.o Calcium—may reduce risk of colorectal adenomas.o Beta carotene—may reduce risk of lung cancer in smokers.

Secondary PreventionScreening and early detection to improve overall outcome and survival:

Performing routine screening tests should be based on whether these tests are adequate to detect a potentially curable cancer in an otherwise asymptomatic person and are also cost effective.

Although all major authorities recommend routine screening for certain types of cancer, each has a different opinion on when screening should begin and how often.

Screening should be based on an individual's age, sex, family history of cancer, ethnic group or race, previous iatrogenic factors (prior radiation therapy or drugs such as DES), and history of exposure to environmental carcinogens.

o Testicular cancer is the most common cancer between ages 20 and 34, the second most common from ages 35 to 39 and the third most common between ages 15 and 19. There is an increased risk in males with undescended testicles, gonadal dysgenesis, and Klinefelter's syndrome. There is also an increased risk in men with a family history of testicular cancer. Although not consistently found to confer a higher risk, infertility or abnormal semen parameters have been associated with a higher risk of testicular cancer in some studies. The American Urological Association (AUA) recommends annual screening beginning at age 15 with monthly testicular self examinations.

o Prostate cancer occurs more commonly in men over age 60. With more widespread screening, younger men are being diagnosed in the early stages of the disease. The ACS and AUA recommend an annual prostate-specific antigen (PSA) and digital rectal examination for men over age 50. The AUA also recommends annual testing for men age 40 and over who are at high risk (black race, family history of prostate cancer).

o Breast cancer is the most common type of cancer in women, and the incidence increases with age. The ACS recommends a clinical breast examination every 3 years from ages 20 to 39 and annually thereafter. Mammography should begin at age 40.

o Colon cancer screening should begin for all men and women over age 50. Patients should be screened with yearly fecal occult blood test, or sigmoidoscopy every 5 years, or double contrast barium enema every 5 years, or colonoscopy every 10 years.

o Lung cancer, although common in both men and women who have smoked, is not routinely screened for because there is no cost-effective method that would detect cancer early enough to make a difference in outcome.

Diagnostic Evaluation

Complete medical history and physical examination. Biopsy of tumor site to determine pathologic diagnosis.

o The malignancy is classified according to anatomic extent and histopathologic analysis.

o Biopsy is obtained from the most accessible site (eg, lymph node versus lung biopsy).

o All original slides should be reviewed with the pathologist. Clinical information should correlate with pathologic diagnosis. Be aware of possible errors and differences in interpretation.

o Classification of tumor type is based on tissue and cellular staining. Differences in cytoplasmic and nuclear staining distinguish one cell type from another and identify their stage of differentiation. The grade of the tumor (rating of 1 to 4) is based on how well differentiated the tissue or cells appear. For most tumors the higher grade, the less differentiated, which is associated with poorer prognosis.

o Flow cytometry testing of tumor tissue determines the DNA content and indicates potential risk of recurrence.

o Estrogen and progesterone levels are obtained from breast and possibly ovarian tissue.

Laboratory tests including complete blood count (CBC) with differential, platelet count, and blood chemistries including liver function tests, blood urea nitrogen (BUN), and creatinine are done to determine baseline values.

o Further tests depend on cancer diagnosis.o Blood markers (carcinoembryonic antigen, PSA, CA15–3, CA125) may

be appropriate to follow response to therapy. Imaging procedures—chest X-ray, nuclear medicine scan, computed tomography

(CT) scan, magnetic resonance imaging (MRI), and positron-emission tomography—are used to determine evidence or extent of metastasis.

StagingStaging is necessary at the time of diagnosis to determine the extent of disease (local versus metastatic), to determine prognosis, and to guide proper management.

The American Joint Committee of Cancer (AJCC) has developed a simple classification system (TNM) that can be applied to all tumor types. It is a numerical assessment of tumor size (T), presence or absence of regional lymph node involvement (N), and presence or absence of distant metastasis.

No standard evaluation exists for all cancers. Work-up depends on the patient, tumor type, symptoms, and medical knowledge of the natural history of that cancer.

MANAGEMENTThe method of treatment depends on the type of malignancy, the specific histologic cell type, stage, presence of metastasis, and condition of the patient. The four modalities of treatment are surgery, chemotherapy, radiation therapy, and biotherapy or a combination of these modalities.

SURGICAL MANAGEMENTThe principles of surgical management are based on a cooperative, multidisciplinary approach to various surgical resources. This is key to the management of the cancer patient. A surgical intervention usually provides the initial diagnosis; subsequent procedures may be needed for treatment.

Diagnosis Biopsy: Tissue is necessary to make a diagnosis of breast cancer.

o Fine-needle aspiration (FNA) is used most commonly to differentiate between solid and cystic masses. It is inexpensive, causes little discomfort, and can be performed in an outpatient or office setting.

o Core-needle biopsy—will yield enough tissue to adequately evaluate the tissue for immunohistochemistry, ie hormone receptors and HER2/neu status. It is highly accurate and can be performed in an office or outpatient setting.

o Open biopsy may be required for some lesions to determine a definitive diagnosis. This is done in the operating room, is more expensive, and requires a longer period of recovery. The biopsy may be incisional, sampling only part of the tumor, or excisional, removing the total tumor.

Classification System of Tumors T—primary tumor Tx—primary tumor is unable to be assessed T0—no evidence or primary tumor Tis—carcinoma in situ T1, T2, T3, T4—increasing size and/or local extent of primary tumor

N—presence or absence or regional lymph node involvement Nx—regional lymph nodes are unable to be assessed N0—no regional lymph node involvement N1, N2, N3—increasing involvement of regional lymph nodes

M—absence or presence or distant metastasis Mx—unable to assess M0—absence of distant metastasis M1—presence of distant metastasis

Treatment and Types of Surgical ProceduresSurgical treatment of cancer focuses on: primary treatment, adjuvant therapy, salvage treatment, and palliative treatment.

Primary treatment—involves the removal of a malignant tumor and a margin of adjacent normal tissue.

o Local excision—is the simple excision of a tumor and a small margin of normal tissue.

o Wide excision—includes the removal of the primary tumor, regional lymph nodes, and neighboring structures.

Adjuvant treatment involves the removal of tissues to decrease the risk of cancer recurrence. It includes debulking procedures.

o Debulking surgery is the removal of the bulk of the tumor; should be performed before the start of chemotherapy whenever possible.

Salvage treatment—involves the use of an extensive surgical approach to treat a local recurrence after implementing a less extensive primary approach.

Palliative treatment—is surgery that attempts to relieve the complications of cancer (eg, obstruction of the GI tract, pain produced by tumor extension into surrounding nerves).

Reconstructive/rehabilitative surgery—is the repair of defects from previous radical surgical resection; can be performed early (breast reconstruction) or delayed (head and neck surgery).

Preventive/prophylactic surgery—is the removal of lesions that, if left in the body, are at risk of developing into cancer. An example is polyps in the rectum or mastectomy in women who are at high risk.

CHEMOTHERAPY FOR CANCERChemotherapy is the use of antineoplastic drugs to promote tumor cell destruction by interfering with cellular function and reproduction. It includes the use of various chemotherapeutic agents and hormones.Principles of Chemotherapy Administration

The intent of chemotherapy is to destroy as many tumor cells as possible with minimal effect on healthy cells.

Cancer cells depend on the same mechanisms for cell division that are found in normal cells. Damage to those mechanisms leads to cell death.

Chemotherapy is utilized in different clinical settings:o As induction chemotherapy for advanced disease

This is given as the primary treatment for patients who present with advanced cancer for which no alternative treatment exists.

As an adjunct to local methods of treatment. Adjuvant chemotherapy is the use of systemic treatment after the

primary tumor has been controlled by surgery and/or radiation therapy. Currently, adjuvant chemotherapy is considered standard treatment for early-stage breast and colorectal cancer. There is also evidence to support the use of chemotherapy after surgical resection of anaplastic astrocytomas

o To palliate symptoms of metastatic disease and or prolong survival. Chemotherapeutic agents can be effective on one of the four phases of the cell

cycle or during any phase of the cell cycle. The cell cycle is divided into four stages:

o G1 (gap one) phase: RNA and protein synthesis (enzymes for DNA synthesis are manufactured)

o S (synthesis) phase: During a long time period the DNA component doubles for the chromosomes in preparation for cell division.

o G2 (gap two) phase: This is a short time period; protein and RNA synthesis occurs, and the mitotic spindle apparatus is formed.

o M (mitosis) phase: In an extremely short time period, the cell actually divides into two identical daughter cells.

o Cells not active in the cell cycle are designated as “resting” (G0). Cells in this phase are, for the most part, refractory to chemotherapy.

Therapeutic strategies:o Adjuvant therapy is given to patients who have no evidence of residual

disease but who are at high risk for relapse. The justifications for adjuvant chemotherapy are the high recurrence rate after surgery for apparently localized tumors, the inability to identify cured patients at the time of surgery, and the failure of therapy to cure these patients after recurrence of disease.

o Neoadjuvant therapy is the administration of several courses of chemotherapy before definitive surgical intervention (eg, large breast masses). The goal of therapy is to decrease the amount of tissue that needs to be removed as well as to attempt to maximize cure potential.

o High dose/intensive therapy is the administration of high doses of chemotherapy, usually in association with growth factor support or before bone marrow transplant/stem cell rescue.

o Preoperative chemotherapy is administered prior to surgery in an attempt to downstage the primary tumor so that less invasive surgery can be performed. For example, patients with large breast tumors can preserve the breast and undergo lumpectomy instead of mastectomy.

o Dose intensification has received increasing emphasis in recent years as a strategy for overcoming resistance to chemotherapy. Malignant cells may be resistant to certain drugs from the start of therapy (natural resistance) or become resistant after therapy has begun (acquired resistance). Dose intensification suggests that chemotherapy should be given in the highest tolerated dose over the briefest interval, with the growth factor support. This is being tested in certain malignancies and remains unproved.

Routes of administration:o Oral—capsule, tablet, or liquido I.V.—push (bolus) or infusion over a specified time periodo Intramuscularo Intrathecal/intraventricular—given by injection via an Ommaya reservoir

or by lumbar punctureo Intra-arterialo Intracavitary—such as peritoneal cavityo Intravesical—into uterus or bladdero Topical

Dosage is based on surface area (mg/m2) in both adults and children. Most chemotherapeutic agents have dose-limiting toxicities that require nursing

interventions. Chemotherapy predictably affects normal, rapidly growing cells (eg, bone marrow, GI tract lining, hair follicles). It is imperative that these toxicities be recognized early on by the nurse.

Frequently Used Chemotherapeutic AgentsDRUG DOSE, ROUTE,

AND FREQUENCY

HOW SUPPLIED

MAJOR ADVERSE EFFECTS OTHER ADVERSE EFFECTS OR COMMENTSMyelosuppressionThrombocytopeniaRisk for

Nausea and Vomiting

AlkylatorsCyclophosphamide (Cytoxan)

500-1,500 mg/m2 I.V. q3-4wk

50-100 mg/m2 PO daily for 14 d

25 mg, 50 mg tablets

100 mg, 200 mg, 500 mg, 1 g, 2 g vials

Marked Mild Moderate

Busulfan (Myleran)

4-8 mg PO, daily

2 mg tablets

Marked Marked Mild

BCNU (Carmustine)

150-200 mg/m2 I.V. q6wk

100 mg vial with 3 mL alcohol diluent

Marked delayed Marked Marked

CBCDA (Carboplatin)

300-500 mg/m2 I.V. q4wk

50 mg, 150 mg, 450 mg vials

Marked Marked Mild

CCNU (Lomustine CeeNU)

130 mg/m2

PO q6wk 10 mg,

40 mg, 100 mg capsules

Marked delayed Marked Moderate

Chlorambucil (Leukeran)

16 mg/m2/ day × 5 d q28d or 0.1-0.2 mg/kg PO

2 mg tablet

Moderate Moderate Mild

daily

Usually 2 mg maintenance

Cisplatin (Platinol) 50-120 mg/m2 I.V. q3-4wk

20 mg/m2 I.V. daily for 5 d q3-4wk

10 mg, 50 mg vial

Moderate Moderate Severe

Dacarbazine (DTIC)

150 mg/m2

daily I.V. × 5 d q4wk

375 mg/m2

on day 1 q15d

100 mg, 200 mg, and 1,000 mg vial

Mild Mild Marked

Ifosphamide (IFEX)

8-12 gm/m2/cycle over 3-5 days every 21-28 days

I.V. for 5 d q3w

1 g, 2 g, 3 g


Mesna 20 mg/kg 15 min before Ifex, repeated q3h for 4 doses

200 mg vial

None None None

MeCCNU (Semustine, Methyl CCNU)

130 mg/m2

q6wk 10 mg,

40 mg, 100 mg capsules

Marked Marked Moderate

Mechlorethamine hydrochloride (nitrogen mustard)

6 mg/m2 day 1 and 8 q28d

10 mg vials

Marked Marked Severe

Melphalan (L-Pam, Alkeran)

0.1 mg/kg/day for 2-3 wk up to 6 mg/m2/d × 5 d q6wk

6 mg orally, daily for 2-4 wk

2 mg tablet

50 mg vial


Procarbazine (Matulane)

2-4mg/kg daily PO

50 mg capsule


Streptozocin (Zanosar)

500 mg/m2

I.V. daily for 5 d q6wk

1 g vialMild Mild Moderate-marked

AntibioticsBleomycin (Blenoxane)

10-20 units/m2 I.V., I.M., S.C. weekly

Total dose not to exceed 400 units

60-120 units in 100 mL normal saline for intracavitary therapy

15 unit vial

Rare Rare Mild

Dactinomycin (Actinomycin D, Cosmegen)

0.010-0.015 µg/kg I.V. for 5 d q3-4wk

0.5 mg vial

Marked Marked Moderate-severe

Daunorubicin (Cerubidine)

60 mg/m2 I.V. for 3 d q3-4wk

480 mg/m2

20 mg vial

Marked Marked Moderate-severe

total I.V. dose

Doxorubicin (Adriamycin)

60-75 mg/m2 I.V. q3wk

30 mg/m2 for 3 d q3-4 wk

Total cumulative dose 550 mg/m2

10 mg, 20 mg, 50 mg vial


Mitomycin (Mutamycin)

10-20 mg/m2 I.V. q6-8wk

5 mg, 20 mg, 40 mg vial


Mitoxantrone (Novantrone)

12 mg/m2 I.V. day 1-3

2 mg/mL in 10 mL, 12.5 mL, 15 mL vial

Moderate Mild Mild

Plant alkaloidsVinblastine (Velban)

5 mg/m2 I.V. q1-2wk

10 mg vial

Marked Marked Mild

Vincristine (Oncovin)

1-2 mg/m2 I.V. maximum single dose

2 mg I.V.

1 mg/mL vial, 2 mg/mL vial

Mild Mild Mild

Vindesine (Eldisine)

2-4 mg/m2 I.V. q1-2wk

10 mg ampule

Moderate Mild Mild

Teniposide (Vm-26)

50-100 mg/m2 I.V. weekly for 4-6wk

10 mg/mL ampule

Moderate Mild Mild

Etoposide (VePesid) (VP-16)

45-75 mg/m2/d 3-5 d q3-5wk

50 mg capsule, 100 mg/5

Moderate Mild Mild-moderate

125-140 mg/m2 PO 3 times/wk q5wk

mL vial

Vinorelbine (Navelbine)

30 mg/m2/ I.V. weekly

10 mg/vial


AntimetabolitesAzacytidine (5-azacytidine)

150 mg/m2

I.V. for 5 d by continuous infusion

100 mg/m2

continuous I.V. infusion q12h q7d

100 mg vial

Marked Marked Severe

Cytarabine (Cytosar, ARA-C)

50-100 mg in 100 mL saline for intrathecal

100 mg vial


5-Fluorouracil (5FU, Efudex)

300-500 mg/m2 I.V. weekly or daily × 5

500 mg ampule cream, 1%, 5%

Moderate-marked Mild Mild

Capecitabine (Xeloda)

2,500 mg/m2×2 daily in two divided doses q14d, repeat every 21d

250 mg & 500 mg tablets

Moderate-marked Mild Moderate-high

Hydroxyurea (Hydrea)

80 mg/kg PO daily

500 mg tablet

Marked Marked Mild

6-Mercaptopurine (6-MP, Purinethol)

70 to 100 mg/m2/day

50 mg tablet

Moderate-marked Moderate-marked Mild

Methotrexate (Mexate)

2.5-5.0 mg PO daily;

2.5 mg Moderated-markedModerate-marked Mild

I.V. or I.M. dose varies

25-50 mg/m2; intrathecal 5-10 mg/m2 q3-7d

tablets

25 mg, 50 mg injection

Thioguanine (6-TG, Tabloid)

2 mg/kg daily PO

40 mg tablet


Gemcitabine (Gemzar)

1,000 mg m2/day I.V. over 30 min once per week for up to 7 wk or until signs of toxicity

200 mg/10 mL vial

1 g/50 mL vial


TaxanesPaclitaxel (Taxol) 175 mg/m2

I.V. over 3 h q3wk, or 60-100 mg/m2 weekly over 1 h

30 mg vial, 6 mg/mL with 5 mL

Marked Mild Mild

Docetaxel (Taxotere)

80-100 mg/m2 I.V. over 1 h q3wk, or 40-80 mg/m2 I.V. weekly

20 mg vial, 80 mg vial

Marked Mild Mild

Miscellaneous drugTopotecan (Hycamtin)

1.5 mg/m2/d for 5d q28d

5 mg vial

Severe Severe Moderate

Safety Measures in Handling ChemotherapyCytotoxic drugs may be irritating to the skin, eyes, and mucous membranes (see Procedure Guidelines 8–1, pages 148 to 150).

Personal Safety to Minimize Exposure via Inhalation Chemotherapeutic agents should be prepared in a class II biologic safety cabinet

(vertical laminar flow hood). Vent vials with filter needle to equalize the internal pressure or use negative-

pressure techniques. Wrap gauze or alcohol pads around the neck of ampules when opening to

decrease droplet contamination. Wrap gauze or alcohol pads around injection sites when removing syringes or

needles from I.V. injection ports. Do not dispose of materials by clipping needles or removing needles from

syringes. Use puncture- and leak-proof containers for non-capped, non-clipped needles.

Personal Safety to Minimize Exposure via Skin Contact Wear nitrile examination gloves at all times when preparing or working with

chemotherapeutic agents. Wash hands before putting on and after removing gloves. Change gloves after each use, tear, puncture, or medication spill or after every 60

minutes of wear. Wear a long-sleeve, nonabsorbent gown with elastic at the wrists and back

closure. Eye and face shields should be worn if splashes are likely to occur. Use syringes and I.V. tubing with Luer locks (which have a locking device to hold

needle firmly in place). Label all syringes and I.V. tubing containing chemotherapeutic agents as

hazardous material. Place an absorbent pad directly under the injection site to absorb any accidental

spillage. If any contact with the skin occurs, immediately wash the area thoroughly with

soap and water. If contact is made with the eye, immediately flush the eye with water and seek

medical attention. Spill kits should be available in all areas where chemotherapy is stored, prepared,

and administered.

Personal Safety to Minimize Exposure via Ingestion Do not eat, drink, chew gum, or smoke while preparing or handling

chemotherapy. Keep all food and drink away from preparation area. Wash hands before and after handling chemotherapy. Avoid hand-to-mouth or hand-to-eye contact while handling chemotherapeutic

agents or body fluids of the person receiving chemotherapy.

Safe Disposal of Antineoplastic Agents, Body Fluids, and Excreta Discard gloves and gown into a leak-proof container, which should be marked as

contaminated or hazardous waste.

Use puncture- and leak-proof containers for needles and other sharp or breakable objects.

Linens contaminated with chemotherapy or excreta from patients who have received chemotherapy within 48 hours should be contained in specially marked hazardous waste bags.

Wear non-sterile nitrile gloves for disposing of body excreta and handling soiled linens within 48 hours of chemotherapy administration.

In the home, wear gloves when handling bed linens or clothing contaminated with chemotherapy or patient excreta within 48 hours of chemotherapy administration. Place linens in a separate, washable pillow case. Wash separately in hot water and regular detergent.

Adverse Effects of ChemotherapyAdverse effects of chemotherapy are graded on a scale of 0 to 4, with 0 being normal and 4 indicating life-threatening. Scoring of adverse effects will determine if a delay in therapy is necessary, dose modification is necessary, or cessation of therapy must occur.Alopecia

Most chemotherapeutic agents cause some degree of alopecia. This is dependent on the drug dose, half-life of drug, and duration of therapy.

Usually begins 2 weeks after administration of chemotherapy. Regrowth takes about 3 to 5 months.

The use of scalp hypothermia and tourniquets is highly controversial.

Anorexia Chemotherapy changes the reproduction of taste buds. Absent or altered taste can lead to a decreased food intake. Concurrent renal or hepatic disease can increase anorexia.

FatigueThe cause of fatigue is generally unknown but can be related to anemia, weight loss, altered sleep patterns, and coping.

Nausea and Vomiting Caused by the stimulation of the vagus nerve by serotonin released by cells in the

upper GI tract. Incidence depends upon the particular chemotherapeutic agent and dosage. Patterns of nausea and vomiting:

o Anticipatory—conditioned response from repeated association between therapy and vomiting.

o Acute—occurs 0 to 24 hours after chemotherapy administration.o Delayed—can occur 1 to 4 days after chemotherapy administration.

Mucositis Caused by the destruction of the oral mucosa, causing an inflammatory response. Initially presents as a burning sensation with no changes in the mucosa and

progresses to significant breakdown, erythema, and pain of the oral mucosa.

Consistent oral hygiene is important to avoid infection.

Anemia Caused by suppression of the stem cell or interference with cell proliferation

pathways. May require red blood cell transfusion or injection of erythropoietin or

darbepoetin.

Neutropenia Defined as an absolute neutrophil count (ANC) of 1,500/mm3 or less. Risk of infection is greatest with an ANC less than 500/mm3. Caused by suppression of the stem cell. Usually occurs 7 to 14 days after administration of chemotherapy. Can be prolonged. Patients should be taught to avoid infection through proper hand washing,

avoiding those with illness, proper hygiene. Patients need to be monitored and treated promptly for fever or other signs of

infection.

Thrombocytopenia Caused by suppression of megakaryocytes. Incidence depends on the agent being used. Risk of bleeding is present when platelet count falls below 50,000/mm3. Risk is high when count falls below 20,000/mm3. Risk is critical when count falls below 10,000/mm3. Patient should be taught to avoid injury, eg, no razors, avoid vaginal douches and

rectal suppositories, and avoid dental floss during the period of thrombocytopenia. May require platelet transfusions if count drops below 20,000/mm3.

Hypersensitivity Reactions Nearly all of the available chemotherapeutic agents can produce hypersensitivity

reactions (HSRs) in at least an occasional patient, and some cause reactions in 5% or more of patients receiving the drug. There are several agents (L-asparaginase, paclitaxel, docetaxel, teniposide, and doxil) for which HSRs are frequent enough to be a major form of treatment-limiting toxicity.

The mechanism is unknown for most of the chemotherapeutic agents in use. Signs and symptoms include hives, pruritus, back pain, shortness of breath,

hypotension, and anaphylaxis. All unexpected drug reactions should be reported to the manufacturer.

Nursing AssessmentIntegumentary System

Inspect for pain, swelling with inflammation or phlebitis, necrosis, or ulceration. Inspect for skin rash, characteristics, whether pruritus, general or local.

Assess areas of erythema and associated tenderness or pruritus. Instruct patient to avoid irritation to skin, sun exposure, or irritating soaps.

Assess changes in skin pigmentation. Note reports of photosensitivity, tearing of the eyes. Assess condition of gums, teeth, buccal mucosa, and tongue.

o Determine whether any taste changes have occurred.o Check for evidence of stomatitis, erythematous areas, ulceration, infection,

or pain on swallowing.o Determine whether the patient has any complaints of pain or burning of

the oral mucosa or on swallowing.

GI System Assess for frequency, timing of onset, duration, and severity of nausea and

vomiting episodes before and after chemotherapy.o Usually occurs from 1 to 24 hours after chemotherapy but may be delayed.

Anticipatory vomiting may occur after first course of therapy. Can be initiated by various cues, including thoughts, smell, or even sight of the medical personnel.

Observe for alterations in hydration, electrolyte balance. Assess for diarrhea or constipation.

o Ascertain any changes in bowel patterns.o Discuss the consistency of stools.o Consider the frequency and duration of diarrhea (the number of stools

each day for the number of days).o Evaluate dietary changes or use of medications such as opioids or 5-HT3

blockers that have had an impact on diarrhea or constipation. Assess for anorexia.

o Discuss taste changes and changes in food preferences.o Ask about daily food intake and normal eating patterns.

Assess for jaundice, right upper quadrant abdominal pain, changes in the stool or urine, and elevated liver function tests that indicate hepatotoxicity.

Monitor liver function tests and total bilirubin.

Hematopoietic System (Of Particular Importance for Patients with Leukemia)

NURSING ALERTFever greater than 101° F (38.3° C) in a patient with an ANC less than 500/mm3 is an emergency requiring immediate administration of antibiotics.

Assess for neutropenia—ANC less than 500/mm3.o Assess for any signs of infection (pulmonary, integumentary, central

nervous system, GI, and urinary).o Auscultate lungs for adventitious breath sounds.o Assess for productive cough or shortness of breath.o Assess for urinary frequency, urgency, pain, or odor.o Monitor for elevation of temperature above 101° F, chills.

Assess for thrombocytopenia—platelet count less than 50,000/mm3 (mild risk of bleeding); less than 20,000/mm3 (high risk of bleeding).

o Assess skin and oral mucous membranes for petechiae, bruises on extremities.

o Assess for signs of bleeding (including nose, urinary, rectal, or hemoptysis).

o Assess for blood in stools, urine, or emesis.o Assess for signs and symptoms of intracranial bleeding if platelet count is

less than 20,000/mm3; monitor for changes in level of responsiveness, vital signs, and pupillary reaction.

Assess for anemia.o Assess skin color, turgor, and capillary refill.o Ascertain whether patient has experienced dyspnea on exertion, fatigue,

weakness, palpitations, or vertigo. Advise rest periods as needed.

Respiratory and Cardiovascular Systems Assess lung sounds. Assess for pulmonary fibrosis, evidenced by a dry, nonproductive cough with

increasing dyspnea. Patients at risk include those over age 60, smokers, those receiving or having had pulmonary radiation, those receiving cumulative dose of bleomycin (Blenoxane), or those with any preexisting lung disease.

Assess for signs and symptoms of heart failure or irregular apical or radial pulses. Verify baseline cardiac studies (eg, electrocardiogram, multiple-gated acquisition

scan/ejection fraction) before administering doxorubicin (Adriamycin) or high-dose cyclophosphamide (Cytoxan).

PROCEDURE GUIDELINES Administering I.V. ChemotherapyEQUIPMENT

Supplies to start I.V. infusion or a running I.V. line Alcohol swabs Specific antidote for extravasation (if indicated) Disposable plastic-backed absorbent liner 4″ × 4″ gauze pads Medication to be administered

ProcedureNursing Action RationalePreparatory phase1. Patient education. 1. Patient education will prepare the patient

for adverse effects, thus increasing tolerance of the drug.

a. Review treatment goals. b. Review the treatment plan and adverse effects of chemotherapy.

c. Review strategies to manage adverse effects.

d. Instruct patient on reportable conditions, eg, fever.

2. Before administering chemotherapy, check for the following:

2. This will minimize chemotherapy administration errors.

a. Order includes any supportive care medications, including premedications, antiemetics, hydration, growth factors, or emergency medications.

a. Antiemetics are more effective if given before administration and on a regular dosing schedule thereafter.

b. Review patient's medication history, including over-the-counter medications, for possible interactions.

b. To reduce or minimize drug interactions and toxicities.

c. Orders include all necessary components: name of drug, route, dosing interval, date, duration of therapy, diluent type and amount, rate of infusion.

d. Compare written orders to drug protocol. If the drug is investigational, verify informed consent.

e. Check against the written order. f. Check current laboratory values; complete blood count, differential, platelets, liver function tests, and creatinine. Notify the health care provider if values are elevated and would preclude infusion of the drug.

f. Drug may be withheld in severe neutropenia, thrombocytopenia, or impaired liver or kidney function.

3. Calculate the dosage according to milligrams per kilogram (mg/kg) or milligrams per meter squared (mg/m2) by body surface area (BSA).

4. Verify the patient's name and identification.

5. Be aware of agents that cause anaphylactic reaction, such as asparaginase, paclitaxel, and docetaxel.

5. Increased awareness. Have emergency resuscitation equipment and drugs available.

Performance phase1. Insert I.V. (if appropriate). 1. a. Select venipuncture site free from sclerosis, thrombosis, or scar formation if possible. If the patient has an established I.V., assess the site for erythema, pain, or tenderness.

a. An optimal I.V. site reduces the risk of extravasation.

b. Check for a blood return by aspirating at a Y-site close to the I.V. catheter. Do not pinch the catheter tubing.

b. Pinching the catheter tubing may dislodge a small clot in a nonpatent I.V.

c. If doubt exists about vein patency or safety of chemotherapy administration, discontinue the administration and treat as an extravasation if a vesicant chemotherapeutic agent has been used.

c. A vesicant is a chemotherapeutic agent capable of causing blistering of tissues and possible tissue necrosis if it extravasates. Some agents are irritants, which cause pain along the vein wall with or without inflammation.

d. Monitor for pain; the patient may describe it as localized to severe burning and radiating along the vein.

e. Examine the site for erythema or swelling

f. If you suspect an extravasation, stop the infusion immediately and follow the procedure described below.

f. Tissue necrosis and sloughing may lead to permanent tissue damage.

2. Administration. 2. a. Use a disposable, absorbent, plastic-backed pad under the work area.

a. To absorb droplets of the drug that may inadvertently spill.

b. Put on protective gown, gloves, and eyewear if necessary.

b. Prevent aerosolization/spillage of drug.

c. If possible, prime all tubing before adding antineoplastics to the bag. If priming occurs at the administration site, the I.V. tubing should be primed with a nondrug fluid.

d. Monitor the patient, particularly during the first 15 minutes, for signs of hypersensitivity or anaphylaxis.

d. Change in mentation or in vital signs may indicate hypersensitivity or anaphylactic reaction.

3. Monitor the I.V. site through the infusion or I.V. push. Use a transparent (not gauze) dressing over the I.V. site.

3. This allows for direct visualization of I.V. site.

Management of extravasation1. If an extravasation is suspected, stop the infusion of the chemotherapy.

2. Disconnect the I.V. tubing and attempt to aspirate all residual chemotherapy in the I.V. catheter using a syringe.

2. To prevent further infusion of chemotherapy agent.

3. Apply warm or cold packs as indicated. 4. Notify the health care provider. 5. If an antidote is available, administer as prescribed.

5. Antidote may prevent tissue necrosis.

a. For subcutaneous administration i. Gently clean the area around the extravasation with an alcohol pad.

ii. Inject the antidote subcutaneously in a circular pattern around the site of the extravasation using a 25G needle. One to

five injections will be needed, depending on the volume of extravasation. Change the needle with each new injection.6. Reapply warm or cold compress as indicated, depending on the chemotherapeutic agent that has been extravasated.

VESICANTSChemotherapeutic Agent Antidote Local CarAdriamycin None Apply cold pack for 15 to 20 minutes at

least 4 times per day.Alkylating agents (nitrogen mustard, cisplatin)

Isotonic sodium thiosulfate

Prepare 1/6 molar solution and inject 1 to 4 mL into existing I.V. and subcutaneous tissue. Heat or cold not proven effective.

Vinca alkaloids (vincristine, vinblastine)

Hyaluronidase Inject hyaluronidase locally and apply moderate heat to disperse drug and minimize pain.

Taxanes (paclitaxel, docetaxel)

Hyaluronidase Mix 300 U with 3 cc of NS. Inject mL for mL infiltrated. Ice has been effective in reducing local tissue damage.

Antimetabolites (5-FU) None—weak vesicant

Follow-up phase 1. Document drug dosage, site, and any occurrence of extravasation, including estimated amount of drug.

1. To document extent of injury.

2. Observe regularly after administration for pain, erythema, induration, and necrosis.

2. If only a small amount of drug extravasated and frank necrosis does not occur, phlebitis may still result, causing pain for several days or induration at the site that may last for weeks or months.

3. Monitor for other adverse effects of infusion.

3.

a. Patient may describe sensations of pain or pressure within the vessel, originating near the venipuncture site or extending 3 to 5 inches (7.5 to 12.5 cm) along the vein.

a. Caused by irritation to the vein.

b. Discoloration-red streak following the line of the vein (called a flare reaction) or darkening of the vein.

b. Flare reaction common with doxorubicin (Adriamycin). Darkening of vein may occur with 5-fluorouracil (5-FU).

c. Itching, urticaria, muscle cramps, or pressure in the arm.

c. Caused by irritation of surrounding subcutaneous tissue.

Neuromuscular System

Determine whether patient is having difficulty with fine motor activities, such as zipping pants, tying shoes, or buttoning a shirt.

Determine the presence of paresthesia (tingling, numbness) of fingers or toes. Evaluate deep tendon reflexes. Evaluate patient for weakness, ataxia, or slapping gait. Determine impact on activities of daily living and discuss changes. Discuss symptoms of urinary retention or constipation. Assess for ringing in ears or decreased hearing acuity.

Genitourinary System Monitor urine output. Assess for urinary frequency, urgency, or hesitancy. Evaluate changes in odor, color, or clarity of urine sample. Assess for hematuria, oliguria, or anuria. Monitor BUN and creatinine.

Nursing Diagnoses Risk for Infection related to neutropenia Risk for Injury related to bleeding from thrombocytopenia Fatigue related to anemia Imbalanced Nutrition: Less Than Body Requirements related to adverse effects of

therapy Ineffective protection and risk for hypersensitivity reaction related to

chemotherapy Impaired Oral Mucous Membranes related to stomatitis Disturbed Body Image related to alopecia and weight loss

Nursing InterventionsPreventing Infection

Monitor vital signs every 4 hours; report occurrence of fever greater than 101° F (38.3° C) and chills.

Provide patient education.o Instruct patient to report signs and symptoms of infection:

Fever greater than 101° F and/or chills Mouth lesions, swelling, or redness Redness, pain, or tenderness at rectum Change in bowel habits Areas of redness, swelling, induration, or pain on skin surface Pain or burning when urinating or odor from urine Cough or shortness of breath

o Reinforce good personal hygiene habits (routine bathing [preferably a shower], clean hair, nails, and mouth care).

o Avoid contact with people who have a transmissible illness.o Encourage deep breathing and coughing to decrease pulmonary stasis.

Avoid performing invasive procedures—rectal temperatures, enemas, or insertion of indwelling urinary catheters.

Monitor white blood cell count (WBC) and differential. Be aware that hematologic nadirs (lowest level) generally occur within 7 to 14

days after drug administration. Length of myelosuppression depends on specific drug. Institution of further therapy usually depends on an adequate WBC and ANC.

Calculate ANC to determine the number of neutrophils capable of fighting an infection by:

Interpretation: 105 of the 700 WBCs are neutrophils and capable of fighting an infection (indicates severe neutropenia).

Administer prophylactic antibiotics as prescribed (if WBC is less than 500). Administer growth factors as prescribed. Neupogen 5 mcg/kg S.C. starting 24

hours after chemotherapy for 10 days for neutropenia prophylaxis or Neulasta 6 mg S.C. for one dose 24 hours after chemotherapy. Should also be administered with subsequent courses of chemotherapy to hasten neutrophil maturity.

Preventing Bleeding Avoid invasive procedures when platelet count is less than 50,000/mm3, including

I.M. injections, suppositories, enemas, and insertion of indwelling urinary catheters.

Apply pressure on injection sites for 5 minutes. Monitor platelet count; administer platelets as prescribed. Monitor and test all urine, stools, and emesis for blood. Provide patient education.

o Instruct patient to avoid straight-edge razors, nail clippers, vaginal or rectal suppositories.

o Avoid intercourse when platelet count is less than 50,000/mm3.o Encourage patient to blow nose gently.o Avoid dental work or other invasive procedures while thrombocytopenic.o Avoid the use of NSAIDs, aspirin, and aspirin-containing products.

Minimizing Fatigue Monitor blood counts (hemoglobin and hematocrit). Administer blood products as prescribed. Administer growth factors as prescribed. Erythropoetin 150 U/kg S.C. 3 × per

week. Provide patient education and counseling

o Information about fatigueo Reassurance that treatment-related fatigue does not mean your cancer is

worseo Why fatigue and shortness of breath may occuro Suggestions for ways to cope with fatigue

Energy conservation Caution the patient about physical overexertion; encourage rest

frequently and warn patient to expect a tired feeling Plan frequent rest periods between daily activities; take naps that

do not interrupt nighttime sleep Set priorities and delegate tasks to others

o Stress managemento Explain that blood transfusions, if given, are a part of therapy and not

necessarily an indication of a setbacko Observe skin coloro Monitor nutritional status

Promoting Nutrition Administer antiemetics before chemotherapy and on a routine schedule (not as

needed). Be aware that certain antiemetic combinations are more effective than single

agents.o A 5-HT3 inhibitor, such as ondansetron (Zofran), granisetron (Kytril),

dolasetron (Anzemet), in combination with dexamethasone (Decadron)o Corticosteroids in combination with metoclopramide (Reglan)

For highly emetogenic chemotherapy regimens:o Premedicate with a 5-HT3 inhibitor and dexamethasone.o Include an as-needed antiemetic such as metoclopramide,

prochlorperazine (Compazine), dexamethasone, or lorazepam (Ativan). For moderately emetogenic regimens:

o Premedicate with either prochlorperazine or dexamethasone with metoclopramide plus diphenhydramine (Benadryl).

o Include an as-needed antiemetic, such as prochlorperazine or lorazepam.o Failures may receive a 5-HT3 inhibitor.

For low emetogenic regimens consider oral prochlorperazine. Extrapyramidal reactions occur frequently in patients under age 30 and over age

65. Treat dystonic reactions with diphenhydramine; treat restlessness with lorazepam.

If delayed nausea and vomiting begin 8 hours after acute prophylactic antiemetic therapy and continue for 24 to 36 hours, administer agents such as metoclopramide with dexamethasone plus diphenhydramine, prochlorperazine, or lorazepam.

Consider alternative measures for relief of anticipatory nausea, such as relaxation therapy, imagery, and distraction.

Encourage small, frequent meals appealing to patient preferences. Encourage patient to eat a diet high in calories and proteins. Provide a high-

protein supplement as needed. Discourage smoking and alcoholic beverages, which may irritate mucous

membranes. Encourage fluid intake to prevent constipation. Monitor intake and output, including emesis.

Consult dietitian about patient's food preferences, intolerances, and individual dietary interventions.

Recognize that the patient may have alterations in taste perception, such as a keener taste of bitterness and loss of ability to detect sweet tastes.

Minimizing Stomatitis Report signs of infection—erythematous areas, white patches, ulcers. Encourage good oral hygiene.

o Soft nylon bristled toothbrush, brush 2 to 3 times daily, rinse frequentlyo Floss once daily

Encourage the use of oral agents to promote cleansing, debridement, and comfort. Mouthwashes with more than 25% alcohol should be avoided.

Assess the need for antifungal, antibacterial, or antiviral therapy (each infection has a different appearance).

Administer local oral therapy such as combinations with viscous lidocaine (Xylocaine) for symptomatic control and maintenance of calorie intake.

Preventing and Managing Hypersensitivity Reactions Be alert for signs of allergic reactions such as pruritus, urticaria, and difficulty

breathing, as well as back pain. Situation may worsen suddenly to hypotension and anaphylaxis.

Stop the medication or infusion immediately, notify the health care provider, and monitor the patient closely. Treatment is supportive and dependent on type of reaction and its severity.

o Do not administer the agent again if there was a severe reaction resulting in significant hypotension.

o Premedicate the patient with antihistamine or corticosteroid as directed if there is a history of moderate reaction.

Strengthening Coping for Altered Body Image Reassure patient that hair will usually grow back; however, it may grow back a

different texture or different color. Suggest wearing a turban, wig, or headscarf, preferably purchased before hair loss

occurs. Many insurance companies will pay for a wig with a prescription. Encourage patient to stay on therapeutic program. Be honest with the patient.

Patient Education and Health Maintenance Make sure that patient uses good hygiene, knows symptoms of infection to report,

and avoids crowds and people with infection while neutropenic. Advise patient to avoid using a razor blade to shave, contact sports, manipulation

of sharp articles, use of hard bristle toothbrush, and passage of hard stool to prevent bleeding while thrombocytopenic.

Advise women to report symptoms of vaginal infection due to opportunistic fungal or viral infection.

Encourage patient participation in plan for chemotherapy and to set realistic goals for work and activities.

Assure patient that changes in menses, libido, and sexual function are usually temporary during therapy.

Evaluation: Expected Outcomes Afebrile, no signs of infection No bruising or bleeding noted; stool and urine heme test negative Denies shortness of breath or severe fatigue Tolerates small, frequent meals following antiemetic No oral lesions or pain on swallowing No urticaria, shortness of breath, or change in vital signs Wears turban, expresses feelings about body image

RADIATION THERAPYRadiation therapy is the use of high-energy ionizing rays to destroy a cancer cell's ability to grow and multiply.The goal of radiation therapy is to deliver a precisely measured dose of irradiation to a defined tumor volume with minimal damage to surrounding healthy tissue. This results in eradication of tumor, high quality of life, prolongation of survival, and allows for effective palliation or prevention of symptoms of cancer, with minimal morbidity.

General Considerations Different irradiation doses are required for tumor control, depending on tumor

type and the number of cells present. Varying radiation doses can be delivered to specific portions of the tumor (periphery versus central portion) or to the tumor bed in cases in which all gross tumor has been surgically removed.

Treatment portals must adequately cover all treatment volumes plus a margin.

Goals of Therapy Curative: When there is a probability of long-term survival after adequate

therapy; some adverse effects of therapy, although undesirable, may be acceptable.

Palliative: When there is no hope of survival for extended periods, radiation can be used to palliate symptoms, primarily pain. Lower doses of irradiation (75% to 80% of curative dose) can control the tumor and palliate symptoms without excessive toxicity.

Principles of Therapy Higher doses of irradiation produce better tumor control. For every increment of

irradiation dose, a certain fraction of cells will be killed. A boost is the additional dose administered through small portals to residual

disease; it is given to obtain the same probability of control as for subclinical aggregates.

Radiosensitivity is the degree and speed of response. This measure of susceptibility of cells to injury or death by radiation depends on cancer diagnosis

and its inherent biologic activity. It is directly related to reproductive capability of the cell.

Role of oxygen: Oxygen must be present at the time of radiation's maximal killing effect. Poor circulation with resultant hypoxia can reduce cellular radiosensitivity. Giving multiple, daily doses allows reoxygenation and enhances radiosensitivity. The dose should allow for repair of normal tissues.

Cellular response can be modified by changing the dose rate, manipulating the process of cell repair, recruiting cells into replication cycle, and using hyperthermia (above 104° F [40° C]).

Radioresistance is the lack of tumor response to radiation because of tumor characteristics (slow-growing tumor, less responsive), tumor cell proliferation, and circulation. Radiation is most effective during the mitotic stage of the cell cycle.

Radioresistant tumors: Many tumors are resistant to radiation, such as squamous cell, ovarian, soft tissue sarcoma, and gliomas. Many other tumors can become resistant after a period of time. Normal radioresistant tissues include mature bone, cartilage, liver, thyroid, muscle, brain, and spinal cord.

Beam energy and penetration: The majority of therapeutic radiation is administered using the cobalt 60 source or high-energy photons from linear accelerators. The radiation beam decreases in intensity with increasing depth. The penetration of the radiation into the body is directly proportional to the generating energy. Linear energy transfer (LET) is the rate at which energy is deposited per unit distance. High-energy electrons are used for tumors on or near the skin surface.

Types of Radiation Therapy

Two general types of radiation techniques are used clinically: brachytherapy and teletherapy.

In brachytherapy, the radiation device is placed within or close to the target tissue. Radiation is delivered in a high dose to a small tissue volume with less radiation to adjacent normal tissue, but requires direct tumor access.

o Interstitial therapy utilizes solid radioactive material such as seed implants. These may be temporary (removed after several days) or permanent. The permanent type remains in place with gradual decay. Implant procedure is performed under local or general anesthesia. Used in breast and prostate disease.

o Intracavitary therapy utilizes radioactive material that is inserted into a cavity such as the vagina, as in cancer of the uterine cervix.

o Surface radiation is used in choroid cancer.o Other forms of brachytherapy are systemic irradiation (parenteral or I.V.),

oral 131I for thyroid cancer, or intraperitoneal radiation. Teletherapy is external beam irradiation and uses a device located at a distance

from the patient. It produces X-rays of varying energies and is administered by machines a distance from the body 31½ to 39 inches (80 to 100 cm).

o Teletherapy is given almost exclusively with supervoltage equipment.

o Most common use of radiation is local therapy.

Chemical and Thermal Modifiers of Radiation Radiosensitization is the use of medications to enhance the sensitivity of the

tumor cells. Radioprotectors increase therapeutic ratio by promoting repair of normal tissues. Hyperthermia is combined with radiation. Uses a variety of sources (ultrasound,

microwaves) and produces a greater effect than radiation alone. It is usually applied locally or regionally immediately after radiation.

Intraoperative radiation therapy involves placement of a targeting cone directly on the tumor site after surgical exposure.

Units for Measuring Radiation Exposure or Absorption Gray (Gy)—a unit to measure absorbed dose. One Gy equals 100 rads. (Rad—

term used in the past to measure absorbed dose.) Joules/kg is also used to measure absorbed dose; 1 joule/kg = Gy.

Roentgen (R)—standard unit of exposure (usually applied to X-ray or gamma rays).

Radiation dose equivalent (rem)—unit of measure that relates to biologic effectiveness (roentgen equivalent in human beings). Standards were established by the International Committee on Radiation Protection (ICRP). The recommendation for maximum permissible dose (MPD) for radiation workers is 5 rems for people over age 18; the maximum dose for women of reproductive capacity is 1.25 rems per quarter at an even rate.

Clinical ConsiderationsNature and Indications for Use

Used alone or in combination with surgery or chemotherapy, depending on the stage of disease and goal of therapy.

Adjuvant radiation therapy—used when a high risk of local recurrence or large primary tumor exists.

Curative radiation therapy—used in anatomically limited tumors (retina, optic nerve, certain brain tumors, skin, oral cavity). Course is usually longer and the dose higher.

Palliative—for treatment of symptoms.o Provides excellent pain control for bone metastasis.o Used to relieve obstruction.o Relief of neurologic dysfunction for brain metastasis.o Given in short, intensive courses.

Radiosurgery (stereotactic)—usually given in single dose fractions.o Indications for radiosurgery include the presence of a radiographically

distinct lesion that has the potential to respond to a single, large dose of radiation.

o The largest use has been in the treatment of arteriovenous malformations (AVMs) and primary and metastatic brain tumors.

o A frame is attached to the patient's skull and used to target the treatment beam.

Treatment Planning Evaluation of tumor extent (staging), including diagnostic studies before

treatment. Define the goal of therapy (cure or palliation). Select appropriate treatment modalities (irradiation alone or combined with

surgery, chemotherapy, or both). All patients undergo simulation and treatment planning.

o Simulation is used to accurately identify target volumes and sensitive structures. CT simulation allows for accurate three-dimensional (3-D) treatment planning of target volume and anatomy of critical normal structures.

o Treatment aids (eg, shielding blocks, molds, masks, immobilization devices, compensators) are extremely important in treatment planning and delivery of optimal dose distribution. Repositioning and immobilization devices are critical for accurate treatment.

o Lead blocks are made to shape the beam and protect normal tissues.o Skin markings are applied to define the target and portal. These are

generally replaced later by permanent tattoos. Usual schedule is Monday through Friday. Actual therapy lasts minutes. Most time is spent on positioning. Determine optimal dose of irradiation and volume to be treated, according to

anatomic location, histologic type, stage, potential regional nodal involvement (and other tumor characteristics), and normal structures in the region.

ComplicationsComplications depend on the site of radiation therapy, type of radiation therapy (brachytherapy or teletherapy), total radiation dose, daily fractionated doses, and overall health of the patient. Adverse effects are predictable, depending on the normal organs and tissues involved in the field.

Acute Adverse Effects Fatigue and malaise Skin: may develop a reaction as soon as 2 weeks into the course of treatment

(Skin erythema may range from mild to severe with possible dry-to-wet desquamation. Areas having folds, such as the axilla, under the breasts, groin and gluteal fold, are at an increased risk because of increased warmth and moisture.)

GI effects: nausea and vomiting, diarrhea, and esophagitis Oral effects: changes in taste, mucositis, dryness, and xerostomia (dryness of

mouth from lack of normal secretions) Pulmonary effects: dyspnea, productive cough, and radiation pneumonitis

(Usually occurs 1 to 3 months after radiation to the lung.) Renal and bladder effects: cystitis and urethritis

Cardiovascular: damage to vasculature of organs, thrombosis (heart is relatively radioresistant)

Recall reactions: acute skin and mucosal reactions when concurrent or past chemotherapy (doxorubicin [Adriamycin], dactinomycin [Actinomycin D])

Bone marrow suppression: more common with pelvic or large bone radiation

Chronic Adverse EffectsAfter 6 months with variability in time of expression:

Skin effects: fibrosis, telangiectasia, permanent darkening of the skin, and atrophy GI effects: fibrosis, adhesions, obstruction, ulceration, and strictures Oral effects: permanent xerostomia, permanent taste alterations, and dental caries Pulmonary effects: fibrosis Renal and bladder effects: radiation nephritis, fibrosis Second primary cancer: patients who have received combined radiation and

chemotherapy with alkylating agents have a rare risk of developing acute leukemia

Nursing Assessment Assess skin and mucous membranes for adverse effects of radiation. Assess GI, respiratory, and renal function for signs of adverse effects. Assess patient's understanding of treatment and emotional status.

Nursing Diagnoses Risk for Impaired Skin Integrity related to radiation effects Ineffective Protection related to brachytherapy

Nursing InterventionsMaintaining Optimal Skin Care

Inform the patient that some skin reaction can be expected, but that it varies from patient to patient. Examples include dry erythema, dry desquamation, wet desquamation, epilation, and tanning.

Do not apply lotions, ointments, or cosmetics to the site of radiation unless prescribed.

Discourage vigorous rubbing, friction, or scratching because this can destroy skin cells. Apply ointments as instructed by health professionals.

Avoid wearing tight-fitting clothing over the treatment field; prevent irritation by not using rough fabric such as wool and corduroy.

Take precautions against exposing the radiation field to sunlight and extremes in temperature.

Do not apply adhesive or other tape to the skin. Avoid shaving the skin in the treatment field. Use lukewarm water only and mild soap when bathing.

Ensuring Protection from Radiation To avoid exposure to radiation while the patient is receiving therapy, consider

the following:

o Time—exposure to radiation is directly proportional to the time spent within a specific distance to the source.

o Distance—amount of radiation reaching a given area decreases as resistance increases.

o Shield—sheet of absorbing material placed between the radiation source and the nurse decreases the amount of radiation exposure.

If exposed to penetrating radiation (X-ray or gamma rays), wear film badges on the front of the body.

Take appropriate measures associated with sealed sources of radiation implanted within a patient (sealed internal radiation).

o Follow directives on precaution sheet that is placed on the charts of all patients receiving radiotherapy.

o Do not remain within 3 feet (1 meter) of the patient any longer than required to give essential care.

Know that the casing material absorbs all alpha radiation and most beta radiation, but that a hazard concerning gamma radiation may exist.

Do not linger longer than necessary in giving patient care, even though all precautions are followed.

Be alert for implants that may have become loosened (those inserted in cavities that have access to the exterior); for example, check the emesis basin following mouth care for a patient with an oral implant.

Notify the radiation therapist of any implant that has moved out of position. Use long-handled forceps or tongs and hold at arm's length when picking up any

dislodged radium needle, seeds, or tubes. Never pick up a radioactive source with your hands.

Do not discard dressings or linens unless you are sure that no radioactive source is present.

After the patient is discharged from the hospital, it is a good policy for the radiologist to check the room with a radiograph or survey meter to be certain that all radioactive materials have been removed.

Continue radiation precautions when a patient has a permanent implant, until the radiologist declares precautions unnecessary.

Evaluation: Expected Outcomes Skin without breakdown or signs of infection Radiation precautions maintained

IMMUNOTHERAPYBiologic therapy is cancer treatment that produces antitumor effects primarily through the action of natural host defense mechanisms. It is capable of altering the immune system with either stimulatory or suppressive effects. Biologic therapy has emerged as an important fourth modality for the treatment of cancer.

Underlying PrinciplesFunction

The primary function of the immune system is to detect and eliminate substances that are recognized as “non-self.”

The Immune SystemTwo major components: nonspecific (innate) and specific (acquired).

Nonspecific or innate immunity is inherent in all individuals. The largest component of the nonspecific system is the skin. Other nonspecific defense mechanisms include mucous membranes, cilia, tears, sebaceous glands, and acidic urine.

Specific or acquired immunity has two primary features—specificity and memory. It is composed of three groups: cell-mediated immunity, humoral immunity, and null cells.

o Cell-mediated immunity is the T cells: T4 (helper/inducer cells) and T8 (cytotoxic and suppressor).

o Humoral immunity is the B cells, which ultimately secrete antibodies.o Null cells are cells that are neither T nor B cells. Their principal function

is still unknown. Natural killer (NK) cells and lymphokine-activated killer (LAK) cells are included in this group.

Types of ImmunotherapyCytokinesCytokines are soluble proteins produced by mononuclear cells of the immune system (usually the lymphocytes and monocytes) that have regulatory actions on other cells in the immune system. Cytokines produced by lymphocytes are referred to as lymphokines, and cytokines produced by monocytes are referred to as monokines.

Examples of cytokines include interleukins, interferons, colony-stimulating factors (CSFs), and tumor necrosis factor (TNF).

Many other biologic agents are currently under investigation.

Antibody TherapyMonoclonal antibodies work on cancer cells in the same way natural antibodies work, by identifying and binding to the target cells. They then alert other cells in the immune system to the presence of the cancer cells.

Promotes targeting cells through antibody-antigen response. Monoclonal antibodies may be used alone or in combination with chemotherapy. Current Monoclonal Antibodies Available or in Late Trials in the United States;

o Rituximab (Rituxan) is a murine/human chimeric monoclonal antibody specific for the CD20 surface marker on B cells. It is approved for the treatment of relapsed or refractory low-grade/follicular non-Hodgkin's lymphoma.

o Ibritumomab (Zevalin)-combines the targeting power of monoclonal antibodies with the cell-damaging ability of localized radiation. It is developed to recognize and attach to substances on the surface of certain cells, and deliver cytotoxic radiation directly to the cancerous cells.

o Trastuzumab (Herceptin) is a recombinant DNA derived humanized monoclonal antibody that selectively binds with high affinity in a cell-

based assay to the extracellular domain of the human epidermal growth factor receptor 2 protein (HER2). It is approved for the treatment of patients with metastatic breast cancer whose tumors overexpress the HER2 protein. Current studies are looking at its use in early stage breast cancer.

o Alemtuzumab (Campath) — recognizes the CD52 antigen expressed on malignant and normal B lymphocytes. It has come to be used therapeutically in B-cell malignancies.

o Iressa — an epidermal growth factor inhibitor, has been shown to inhibit lung and bladder cancers.

o Avastin — is approved for colorectal cancer and being studied in breast, ovarian, and lung cancers.

Potential adverse effects of monoclonal antibodies include: dyspnea, and mild wheezing, fever and chills, headache, rash, nausea and vomiting, tachycardia, and allergic reactions.

Nursing Assessment Review patient's chart or obtain history from the patient to determine site of

cancer, previous cancer therapies, current medications, and other medical conditions.

Assess current cardiovascular and respiratory status. Assess patient's understanding of immunotherapy and associated toxicities.

Nursing Diagnoses Hyperthermia as a adverse effect of immunotherapy Ineffective Tissue Perfusion related to capillary permeability leak syndrome (third

spacing of fluid) caused by immunotherapy

Nursing InterventionsControlling Hyperthermia

Discuss the overall goal of immunotherapy, expected adverse effects, and the method of administration.

Instruct the patient to report fever, chills, diarrhea, nausea and vomiting, itching, or weight gain.

Administer or advise self-administration of antipyretics such as acetaminophen (Tylenol) for fever.

Emphasize that adverse effects are temporary and will usually cease within 1 week after treatment ends.

Maintaining Tissue Perfusion Monitor vital signs at least every 4 hours for hypotension, tachycardia,

tachypnea, and fever.o Instruct patient to remain in bed if blood pressure is low.o Monitor apical heart rate.

Assess respirations for rate and depth, and auscultate breath sounds for evidence of pulmonary edema.

Assess for signs of restlessness, apprehension, discomfort, or cyanosis, which may indicate respiratory distress.

Administer oxygen as prescribed. Maintain patent I.V. line and administer serum albumin as prescribed. Check extremities for warmth, color, and capillary refill.

Evaluation: Expected Outcomes Relief of fever after medication Blood pressure stable; lungs clear

SPECIAL CONSIDERATIONS IN CANCER CARE

PAIN MANAGEMENTPain related to cancer may be caused by direct tumor infiltration of bones, nerves, viscera, or soft tissue or by prior therapeutic measures (surgery, radiation).

Incidence Pain is the most common symptom associated with cancer. The incidence of pain in cancer patients increases with progression of disease and

ultimately affects 70% of all cancer patients. 90% of patients with cancer pain are those with advanced disease.

About 50% of physicians believed that they gave their cancer patients insufficient analgesic drugs for pain control, and 30% indicated they would not use maximally effective analgesic doses until they felt that the patient's life expectancy was less than 6 months.

Cancer pain can be controlled with medication in 80% of patients.

Causes of Pain Pain induced by the disease due to direct tumor involvement of bone, nerves,

viscera, or soft tissue. Pain induced by the treatment including surgery, chemotherapy, and

immunotherapy.

Types of Pain Somatic pain—caused by direct tumor involvement of sensory receptors in

cutaneous and deep tissueso Usually described as dull, sharp, aching, and throbbing; usually constant

and localized.o Most common somatic pain is bone pain caused by metastasis.o Can usually be controlled with NSAIDs or oral opioids.

Neuropathic paino Results from nerve injury or compressiono Includes phantom pain and postherpetic neuralgiao Described as burning, shooting, electric, and lancinating (It can be

constant or sporadic.)o Usually associated with paresthesia

o Treatment usually includes combinations of antidepressants, anticonvulsants and opioids

Visceral paino Usually described as deep, dull, aching, squeezing, or pressure sensation.

It can be vague or ill-defined and can be referred to cutaneous sites, making it difficult to differentiate from somatic pain.

o Usually caused by abnormal stretching of smooth muscle walls, ischemia of visceral muscle, and serosal irritation.

o Can be treated with oral opioids or surgery to remove the cause.

Other Clinical Manifestations Fatigue from sleep disturbances—most patients have not slept for extended

periods Loss of appetite, weight loss, anxiety, and depression Change in self-concept and quality of life

Principles of Pain Management The goal of pain management is complete relief of pain. Placebos are never indicated for the treatment of pain. Physical dependence and tolerance commonly occur; patients may require

escalating doses of medications to control pain. It is essential that physicians and nurses do not confuse addiction with tolerance.

Addiction is an unrelated medical disorder with behavioral components. These facts must also be stressed with patients who are reluctant to take medications.

Pharmacologic Management

Non-opioid analgesics Acetaminophen—a centrally acting analgesic; does not have anti-inflammatory or

antiplatelet activities. NSAIDs:

o Produce analgesia by decreasing levels of inflammatory mediators such as prostaglandins at the site of tissue injury.

o Suppress platelet function, decrease creatinine clearance, and interfere with the protective effect of prostaglandins on the gastric mucosa.

o Used to treat mild to moderate pain; examples include ibuprofen (Motrin) 400 to 800 mg po tid; nabumetone (Relafen) 500 to 1,000 mg po bid; indomethacin (Indocin) 25 to 50 mg po tid.

o COX-2 inhibitors are NSAIDs that are somewhat selective for cyclooxygenase 2 (COX-2) compounds, present in most tissues but less present than COX-1 in gastric mucosa. COX-2 is induced in response to inflammation and converts arachidonic acid to prostaglandin. COX-2 inhibitors inhibit prostaglandins at the site of inflammation but cause less GI irritation and bleeding. Examples include rofecoxib (Vioxx) 12.5 to 25 mg po qd-bid; celecoxib (Celebrex) 100 to 200 mg po bid; valdecoxib (Bextra), 10 to 20 mg po bid.

Corticosteroids—may decrease edema associated with tumor invasion of neural tissue, eg, spinal cord compression.

o Typically used for headache associated with brain tumors.o Examples include dexamethasone (Decadron) 4 to 10 mg po qd to tid

(dosage varies); prednisone 5 to 60 mg po qd (dosage varies). Bisphosphonates—used for lytic bone lesions to prevent fractures and may help

control bone pain. Examples include zoledronic acid (Zometa) 4 mg I.V. q3 to 4wk; pamidronate (Aredia) 90 mg I.V. q4 wk.

Anticonvulsants and antidepressants for neuropathic pain— used to enhance the effect of opioids. Examples include amitriptyline (Elavil) 25 to 100 mg po qhs (may cause drowsiness); gabapentin (Neurontin) 300 to 600 mg qd to tid.

Opioid analgesics Oral route is preferred unless patient cannot swallow or absorb medications

through the GI tract. Doses should be adjusted to achieve pain relief with an acceptable level of adverse effects.

Most important to administer on a schedule rather than an as-needed basis. Optimal treatment approach is to treat with long-acting drugs to control baseline

pain, paired with short-acting drugs as needed for breakthrough pain. Oral opioids—primary course of treatment for moderate to severe pain; produce

analgesia by binding to specific opiate receptors in the brain and spinal cord.o Short-acting opioids—examples include morphine (MSIR), oxycodone

(OxyIR), or hydromorphone (Dilaudid) may be used for breakthrough pain. Relief lasts 3 to 4 hours.

o Long acting- dosage should be equivalent to daily dose of short acting opiates. Examples include MS Contin, OxyContin. Should be prescribed q8 to 12 hours.

o Fentanyl (Duragesic) is a transdermal patch applied to the skin and is changed every 3 days. The peak effect is delayed for up for 3 days after applying. Should be used for patients with stable opioid requirements.

Parenteral administration of opioids are used for patients who cannot tolerate oral opioids or who are in an acute pain crisis.

o Patient-controlled analgesia (PCA)—administered by either subcutaneous (S.C.) or I.V. route using a computer-assisted drug delivery system.

o S.C. infusion of morphine should not exceed 5 ml/hour. Intraspinal administration of opiates for management of acute or chronic pain:

o A catheter is placed into spinal epidural or subarachnoid (intrathecal) space.

o Catheter may be placed percutaneously and sutured in site or tunneled subcutaneously to the abdominal wall and exteriorized, or the pump system may be implanted.

o Catheter is positioned as near as possible to the spinal segment where the pain is projected.

o Preservative-free sterile morphine or other analgesic or local anesthetic drug is injected into the system at specified intervals.

o May be delivered by PCA pump, or by continuous or intermittent infusion.

o Spinally administered local anesthetics produce their effects predominantly by action on axons of spinal nerve roots; produce long-lasting pain relief with relatively low doses with little or no blunting of patient's level of responsiveness.

o Complications of intraspinal administration include respiratory depression, urine retention, pruritus, infection, leakage, technical problems, and development of tolerance.

Nursing Assessment and InterventionsTo provide effective pain management, nursing assessment, physical examination, and review of laboratory values are very important. See Standards of Care Guidelines.

STANDARDS OF CARE GUIDELINES

Pain ManagementTo provide appropriate pain management for patients with cancer or other illnesses or injuries, consider the following:

Assess pain repeatedly by questioning patient, looking for nonverbal signs of pain, and using appropriate pain rating scale.

Administer analgesics on round-the-clock schedule as indicated with as-needed dosing for breakthrough pain.

Utilize combination analgesic regimens and adjunct medications, such as antiemetics, antidepressants, and antianxiety agents as needed for patient's comfort.

Help the patient employ nonpharmacologic measures, such as relaxation techniques, distraction, and massage.

Assess for adverse reactions and patient's response to pain relief measures, and alter pain management plan as indicated.

Communicate any significant adverse reactions or failure to provide adequate pain relief to health care provider.

FootnoteThis information should serve as a general guideline only. Each patient situation presents a unique set of clinical factors and requires nursing judgment to guide care, which may include additional or alternative measures and approaches.

Screen for pain at each visit. Evaluate objectively the nature of the patient's pain, including location, duration, quality, and impact on daily activities. Pain self-assessment is the most reliable guide to both cause of the pain and the effectiveness of pain treatment.

Assess patient history and physical examination findings and laboratory values to differentiate expected pain from pain due to a new problem, an oncologic complication, or worsening of the underlying process.

Use a pain intensity scale of 0 (no pain) to 10 (worst possible pain) or other pain scale as appropriate. Take careful history of prior and present medications, response, and adverse effects.

Assess relief from medications and duration of relief. (Use the same measuring scale every time.)

Base the initial analgesic choice on the patient's report of pain. Administer drugs orally whenever possible; avoid I.M. injection. Administer analgesia “around the clock” rather than as needed. Convey the impression that the patient's pain is understood and that the pain can

be controlled. Take a careful pain history. Explore pain interventions that have been used and

their effectiveness. Determine whether the intensity of the pain correlates with the prescribed analgesic.

Reevaluate the pain frequently. The requirement for analgesia should decrease if other treatment is given, including radiation or chemotherapy.

Use alternative measures to relieve pain such as guided imagery, relaxation, and biofeedback.

Provide ongoing support and open communication. Consider referral to a pain specialist for intractable pain. Instruct patients that there is no benefit to suffering and that addiction is not a

problem.o Instruct patients that taking these medications now does not mean that

they will not work later.o Encourage patients to talk to their physician or nurse about their pain and

effectiveness of the treatment plan.o Assure patients that there are other options if the medications prescribed

do not work.

Patient Education Provide a complete list of each medication prescribed with instructions on how to

take each one. Educate patients on the adverse effects of pain medications and ways to manage

them.o Respiratory depression is a potentially life-threatening adverse effect of

opioids, however, patients generally develop a tolerance.o Constipation is expected with opioids and is treated prophylactically.o Nausea is usually transitory and controllable with prophylactic

antiemetics.o Sedation is common initially and is transitory.

Educate patients to administer medications as necessary, ie, pump instruction and catheter and exit site care.

Provide home care assistance as needed.

ONCOLOGIC EMERGENCIES

Septic ShockSeptic shock is a systemic disease associated with the presence and persistence of pathogenic microorganisms or their toxins in the blood. It is characterized by hemodynamic instability, abnormal coagulation, and altered metabolism.

Risk Factors Neutropenia, ANC less than 500 Patients who are neutropenic longer than 7 days are most susceptible Patients with HIV and concomitant neutropenia Prolonged hospitalization Elderly patients Patients with co-morbid conditions such as diabetes and pulmonary diseases

Clinical Manifestations Fever greater than 100.1° F (37.8° C) Warm, flushed, dry skin Hypotension Tachycardia Tachypnea Decreased level of consciousness Decreased urine output

Diagnostic Evaluation Vital signs Culture—blood, urine, stool, sputum, central and peripheral I.V. lines, and any

open wounds to determine source and type of infection Chest X-ray—to detect underlying pneumonia CT scans as necessary Arterial blood gas analysis—decreased pH reflects acidosis BUN and creatinine—elevated due to decreased circulating blood volume CBC with differential—elevated WBC with shift to left

Management Antibiotics are started immediately; broad-spectrum antibiotics are given until

organism is identified. I.V. fluids and plasma expanders are used to restore circulating volume. Colony-stimulating factors are administered to increase neutrophil count. Vasopressors are administered to support blood pressure. Oxygen is administered as needed to prevent tissue hypoxia. Vital signs, respiratory status, urine output, and any signs of bleeding are

monitored carefully. Complications such as renal failure, respiratory failure, cardiac failure, metabolic

acidosis, and disseminated intravascular coagulation are treated aggressively.

Spinal Cord CompressionSpinal cord compression (SCC) is the result of tumor compression on the spinal cord or thecal sac or in the epidural space. It is associated with vertebral metastasis.

Incidence 50% of diagnosed cases occur in patients with lung, breast, or colon cancer.

SCC is the second most common neurologic complication of cancer.

Clinical Manifestations Cervical spine

o Vertigoo Radicular pain in neck and back of head that is aggravated by neck flexiono Upper extremity weaknesso Sensory loss in area of weakness, ie, paresthesia, numbnesso Abnormal deep tendon reflexeso Gastric hypersecretion and paralytic ileus

Thoracic spineo Local or radicular pain (or both)o Lower extremity weaknesso Sensory loss below the level of the lesiono Band of hyperesthesia at dermatome of tumor siteo Impaired bladder or bowel control

Lumbar spineo Local or radicular pain (or both)o Lower extremity weakness, paralysiso Atrophy of lower extremity muscleso Sensory loss below level of the lesiono Urinary symptoms (hesitancy, retention), constipation, or bowel

incontinence Weakness and unsteadiness may be noted before changes in motor function

(Progression is usually rapid with foot drop and impaired ambulation. Urgent investigation and treatment are crucial to minimize the risk of paraplegia. The degree of weakness and ability to walk at presentation are important clinical predictors of outcome.)

Changes in sensation—paresthesia, numbness, tingling (Severity usually mirrors the severity of motor weakness.)

NURSING ALERTAny abnormal neurologic symptoms in a patient with cancer should be considered an SCC until proven otherwise.

Diagnostic Evaluation Neurologic examination—early diagnosis is important. X-ray of the painful site—may be abnormal; can be used as an initial screen for

complaints of back pain. Bone scan—more sensitive to bony metastasis than X-ray to detect abnormal

vertebral bodies. MRI—most useful in detecting spinal cord lesions. The entire spine can be

viewed. Immediately indicated if radiculopathy or myelopathy is present or X-rays are abnormal.

Myelogram with CT scan—no longer used unless MRI equipment is unavailable or patient cannot tolerate MRI scanner.

Management Treatment is usually palliative because it is associated with metastatic disease. Treatment goals are to relieve pain and preserve or restore neurologic function. Corticosteroids are the initial treatment until more definitive treatment can be

instituted; reduce inflammation and swelling at site, increase neurologic function, and relieve pain.

o A loading dose of decadron at 100 mg is usually given followed by tapering doses over a period of days.

o Steroids must be tapered and not abruptly discontinued.o Monitor patient's glucose levels while on decadron; it can cause

hyperglycemia. Radiation therapy to the tumor on spinal column is the most common

treatment.o A common dose is 3,000 cGy, delivered in 10 fractions over a period of

2½> weeks. Surgery (laminectomy) is considered when tumors are not radiosensitive or

located in an area that has been previously radiated. It is also indicated with spinal instability.

Complications Respiratory impairment, including pneumonia and atelectasis Mobility impairment, foot drop, skin impairment, postural hypotension Sensory losses creating safety concerns Bladder or bowel dysfunction

Patient Education Facilitate referral to home care services for nursing assessment, nursing

intervention, and rehabilitation for residual deficits. Facilitate referral to appropriate outpatient services, including physical therapy,

occupational therapy, and psychosocial support. Provide instruction about safety issues for residual sensory deficits (eg, test bath

water temperature, careful use of extreme hot or cold).

HypercalcemiaHypercalcemia is an elevated serum calcium level above 11 mg/dL. It results when bone resorption exceeds both bone formation and the ability of the kidneys to excrete extracellular calcium released from the bones.

Incidence The most common life-threatening disorder associated with malignancy; occurs in

10% to 20% of patients with cancer. Occurs most commonly in patients with carcinoma of the lung, breast, prostate,

and multiple myeloma.

Can occur with or without skeletal metastasis, but more than 80% of patients do have bony disease.

Clinical Manifestations Signs and symptoms may vary, depending on the severity, and may be

nonspecific and insidious.o Early symptoms include anorexia, weakness, polyuria, polydipsia, and

fatigue.o Late symptoms include apathy, irritability, profound muscle weakness,

nausea, vomiting, constipation, pruritus, vision disturbances. A rapid and life-threatening increase in calcium may cause dehydration, renal

failure, coma, and death.

Diagnostic Evaluation Serum calcium level greater than 11 mg/dL in adults. Electrolyte levels, BUN, and creatinine are obtained to determine hydration status

and renal function. ECG may show shortening of the QT interval and prolongation of the PR interval.

Management Management includes treating the primary malignancy with chemotherapy,

surgery, or radiation. Acute, symptomatic hypercalcemia should be treated as an emergency. Hydration and diuresis—I.V. normal saline (0.9% NaCl) is the initial treatment

for patients with acute hypercalcemia and clinical symptoms, to dilute the calcium and promote its renal excretion. Diuresis is induced with furosemide (Lasix). (Thiazide diuretics aggravate hypercalcemia and should be avoided.)

Pharmacotherapy includes:o Bisphosphonates are primary drug therapy; administered I.V.

(pamidronate [Aredia] or zoledronic acid [Zometa]) inhibit osteoclast resorption in the bone.

o Plicamycin (Mithracin)—blocks PTH and may also inhibit bone resorption. Not readily used since the availability of bisphosphonates. It is contraindicated in severe thrombocytopenia and hepatic dysfunction.

o Calcitonin—used in combination with glucocorticoids, inhibits bone resorption. It has a rapid onset but a short duration of action. Used more commonly in patients with multiple myeloma.

Nursing Interventions Prevent and detect hypercalcemia early.

o Recognize patients at risk and monitor for signs and symptoms, such as nausea and vomiting, constipation, lethargy, and anorexia.

o Emphasize importance of mobility to minimize bone demineralization and constipation.

o Instruct patient on the importance of adequate hydration. Administer normal saline infusions as prescribed.

Administer medications as prescribed. Maintain accurate intake and output; observe for oliguria or anuria. Take vital signs every 4 hours, especially apical pulse and blood pressure. Monitor electrolyte values and renal function. Assess mental status. Assess cardiorespiratory status for signs of fluid overload.

Superior Vena Cava SyndromeSuperior vena cava syndrome (SVCS) is obstruction and thrombosis of the superior vena cava by a tumor or an enlarged lymph node, resulting in impaired venous drainage of the head, neck, arms, and thorax.

Incidence 80% to 95% of patients with SVCS are cancer patients. Occurs most commonly in men ages 50 to 70 who have tumors of the

mediastinum (primary or metastatic). 75% of cases arise from advanced lung cancer, specifically small cell lung

cancers. Other malignancies associated with SVCS include Hodgkin's and non-Hodgkin's

lymphoma, thymoma, and breast cancer.

Clinical Manifestations Signs and symptoms may vary, depending on the degree of obstruction and how

rapidly the obstruction occurs. A rapid onset of SVCS is dramatic, potentially life-threatening, and requires

immediate intervention. Early symptoms include progressive dyspnea, cough, feeling of fullness in the

head, difficulty buttoning shirt collar (Stoke's sign), dysphagia and hoarseness, chest pain.

Cyanosis and edema of the head and upper extremities may be apparent. Collateral circulation with dilated chest wall veins may be visible.

Late symptoms include respiratory distress, headache, vision disturbances, dizziness and syncope, lethargy, irritability, and mental status changes.

Pleural effusion on chest X-ray may also be seen.

Diagnostic Evaluation 60% of SVCS cases can be detected on plain chest X-ray. CT scan may be necessary to make the diagnosis for some patients, but is usually

used to determine the extent of tumor and obstruction.

Management Radiation therapy is the gold standard of treatment for SVCS to reduce tumor size

and relieve pressure. Most patients experience a relief of symptoms within the first 4 days of therapy.

Chemotherapy may be used in conjunction with radiation. Specific chemotherapeutic agents depend on the tumor type.

Surgery is rarely used due to the associated high morbidity and mortality risks. Percutaneous stent placement may reopen occluded vessels. Thrombolytic and anticoagulant therapy may be used if a thrombus is suspected

or to prevent the formation of a thrombus; must be used within the first 7 days to be effective.

Oxygen is given for relief of dyspnea and maintenance of airway. Analgesics and tranquilizers are used for discomfort and anxiety.

Nursing Interventions Administer oxygen as prescribed to relieve hypoxia. Place patient in Fowler's position—facilitates gravity drainage and reduces facial

edema. Limit patient's activity and provide a quiet environment. Reassure patient that cyanotic color and facial edema will subside with treatment.

CLINICAL TRIALSA clinical trial is a scientific study designed to answer important clinical and biological questions. Trials provide a mechanism to tests the effectiveness of new drug and other therapies. Clinical trials are important in the advancement of cancer treatment.

Phases of Clinical TrialsPhase I Trials

Phase 1 studies are offered to patients who have failed conventional therapy or for whom there is no treatment known to be superior.

Phase 1 trials are given to patients with various types of cancer to:o Evaluate drug toxicities.o Establish the maximum tolerated dose of the drug.o Evaluate how the drug is metabolized or the pharmacokinetics of the drug.

Phase II Trials To determine tumor activity in specific tumor types To design administration techniques To determine dose modifications

Phase III Trials Designed to compare drugs with standard therapy Evaluate response and duration of response

Phase IV Trials Designed to determine new ways to use the drug Determine effectiveness in the adjuvant setting

Nursing Interventions Educate patients about the clinical trial process. If involved in clinical trials, follow protocol and documentation as indicated. Report all adverse events during the trial period.

Refer patients who are interested in clinical trials to CancerTrials at http://www.cancertrials.nci.nih.gov.

PSYCHOSOCIAL COMPONENTS OF CARENursing Assessment

Assess lifestyle before illness. How did patient solve other problems? Assess for signs of anxiety and coexistence of depression: agitation and

restlessness, sleep disturbances, excessive autonomic activity, weight gain or loss, mood changes.

What activities of daily living can the patient perform? What changes in lifestyle have resulted from cancer and its treatment? Determine the patient's perception of the disease and treatment. Evaluate available social support; who is the most significant other? Ask patient if any complimentary or alternative modalities (CAM) are being

utilized for cancer treatment. Be aware that many patients seek herbal and other remedies despite lack of scientific evidence of any benefit. Encourage patient and family to discuss CAM use with health care provider to ensure safety.

Try to gain a sense of emotional strengths and potential problem areas. Ask if patient and family have a plan for end-of-life care as appropriate.

Alternative TherapiesIn an effort to increase their chances of survival, bring a measure of control, and minimize adverse effects, many patients are turning to alternative therapies. Herbs are popular and have been used to treat cancer since 2838 BC. Many of these herbs, however, have not been adequately researched, so their impact on cancer is not known. Listed below are some common herbs, their commercially advertised benefits, and some medically identified risks.HERB ADVERTISED BENEFIT PRECAUTIONSIscador Derived from mistletoe; said to

activate defense functions and help prevent metastatic spread after surgery.

None known

Laetrile Derived from apricots and almonds—promoters say that enzymes in malignant neoplasms trigger the release of hydrogen cyanide from the drug. The cyanide is claimed to stop tumor respiration and kill the cancer cells.

Has caused cyanide poisoning

Urtica Derived from stinging nettle; used for prostate cancer in Germany.

Can be irritating to the stomach

Essiac Made from Indian rhubarb; thought to have anticancer activity.

Studied in the 1980s; found to have no antitumor activity

Lily Worldwide folk use for cancers. Can be toxicEchinacea Currently under investigation in liver

and colon cancer for immune Has cortisone-like activity

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stimulation.Hoxsey Folk use in India; thought to have

anticancer activity.Excessive use can cause headache, lethargy, heart failure, cardiac arrest

Pau d'Arco Anticancer activity noted, but studies were discontinued.

Extremely toxicNausea, vomiting, potential for hemorrhage

Green tea Chinese remedy; thought to have anticancer activity.

Linked with high rates of esophageal cancer if consumed heavily

Ginseng Old Chinese remedy; thought to stimulate immune system.

Overdose may cause hemorrhage, vomiting, or deathEstrogen-like properties

Chaparral Used as an anticancer treatment. Should not be taken orally—can cause hepatic failure

Chlorella Single-celled, freshwater green alga used orally as a food supplement and source of nutrients, including protein, nucleic acids, fiber, vitamins, and minerals; also used orally for cancer prevention, stimulating the immune system, increasing white blood cell counts (eg, in people with human immunodeficiency virus infection or cancer), preventing colds, to protect the body from the effects of radiation.

None known

Shark cartilage

Orally, shark cartilage is used for preventing and treating cancer, arthritis, psoriasis, and wound healing. It is also used for enteritis, diabetic retinopathy, and cutaneous Kaposi's sarcoma. Topically, shark cartilage is used for arthritis. Rectally, shark cartilage is used for cancer.

Shark cartilage appears to offer no benefit to people with advanced, previously treated cancer, including breast, colorectal, lung, prostate, non-Hodgkin's lymphoma, and brain cancer. However, studies of shark cartilage in people with less advanced cancer or in combination with other cancer treatments have not been published

Lentinan Polysaccharide derived from shiitake mushroom. Lentinan is not directly cytotoxic, but may augment natural killer cell activity, activate macrophages and enhance T-helper cell function.

None known

Sangre de grado (Dragon's blood)

Sangre de grado is a tree native to the Amazon regions of South America. The resin, a viscous red latex, and bark have a long history of oral and topical medicinal use; reported to have anti-inflammatory, antibacterial,

No serious toxicities have been reported

antihemorrhagic, antiseptic, and antitumor properties.

Nursing Diagnoses Anxiety related to complex disease process, treatment options, and prognosis Ineffective Coping related to life-altering disease process Fear of death and dying

Nursing InterventionsReducing Anxiety

Establish and sustain an unhurried approach to give the patient time to organize fears, thoughts, and feelings.

Allow patient to share feelings about having cancer. Reflect and amplify insights and judgments; try to reduce anxiety through

reflection and reorientation. Recognize feelings of losing control. Discuss methods of stress reduction (imagery, relaxation). Discuss the positive aspects of treatment. Encourage expression of positive emotions—emphasis on living in the here and

now, greater appreciation of life. Reinforce effective coping behaviors. Encourage patient to join a support group. Refer to local chapter of the American

Cancer Society, call 1–800-ACS-2345 or visit http://www.cancer.org. Remain available as problems arise. Give patient telephone numbers of people to

call when needed. Initiate referrals for additional rehabilitation and psychosocial services as

appropriate.

Promoting Effective Coping Encourage patient and family members to enroll in cancer education program. Encourage patient to learn everything about treatment plan, because this promotes

a sense of control. Provide expert physical care and teach patient about care. Assist patient in strengthening support system (family, friends, visitors, health

care staff and volunteers, support groups)—strengthens self-esteem through the experience of feeling accepted and valued.

Help patient readjust expectations and goals to promote ongoing adjustment. Support patient in coping mechanisms chosen.

Allaying Fear of Death and Dying Educate patient and family about prognosis and end-of-life choices, as outlined by

patient's health care provider. Be direct, stating the statistics, but stressing the positive aspects of the situation.

Assess and respect the patient's beliefs. Help the patient and family agree on goals. Facilitate emotional support for the patient.

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Provide bereavement support to survivors.

Evaluation: Expected Outcomes Discusses feelings; practices stress reduction Asks questions about prognosis and sets goals for care Patient and family attend cancer education program

PALLIATIVE CAREPalliative care is the active total care of patients with advanced illness. The focus is no longer on curative treatment, but on quality of life and integrating the physical, psychological, spiritual, and social aspects of care. Although palliative care is appropriate for many cancer patients, it is not limited to cancer; many neurologic, cardiac, pulmonary, and other types of disorders call for palliative care in their more severe or advanced forms.In the past few decades, a number of palliative care programs have emerged in various settings across the United States. There are hospital- and community-based programs as well as inpatient facilities and home care services (including hospice). Care of patients with advanced illness, such as cancer, and dealing with death and dying is an integral part of oncology nursing. Most medical residents and nursing students do not get adequate training in palliative care. However, this is beginning to change. More medical and nursing programs are incorporating palliative care education into their curriculums.The following resources offer information pertaining to palliative and end-of-life care:

Center to Advance Palliative Care: http://www.capcmssm.org (for health care professionals)

End of Life/Palliative Education Resource Center: http://www.eperc.mcw.edu (for health care professionals)

Last Acts: http://www.lastacts.org (for health care professionals and consumers) Hospice Foundation of America: http://www.hospicefoundation.org (for

consumers) National Hospice and Palliative Care Organization: http://www.nhpco.org (for

consumers)

Principles of Palliative Care Palliative care is an interdisciplinary team approach including experts from

medicine, nursing, social work, the clergy, and nutrition. This team approach is needed to make the necessary assessments and to institute appropriate interventions.

The essential components of palliative care are relief of symptom distress, improved quality of life, opening of communication on a regular basis with patients to provide appropriate care on their terms, and psychosocial support for patients and families.

The goal is not to cure but to provide comfort and maintain the highest possible quality of life for as long as possible.

The traditional focus of palliative care is not on death but on a compassionate, specialized care for the living. It is based on a comprehensive understanding of

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patient suffering and focuses on providing effective pain and symptom management to seriously-ill patients while improving quality of life.

End-of-Life Care Hospice and palliative care both provide care during progressive illness, but

hospice eligibility begin only when a patient has a life expectancy of 6 months or less. In contrast, palliative care begins when the patient has been diagnosed with a life-limiting illness. It recognizes that the goals of care may change, but the focus is always on quality of life.

Unfortunately, hospice is equated with care of the dying, causing it to be underutilized; thus many patients only live a few days to a week after contacting hospice.

Hospice care and palliative care offer end-of-life care. Quality at end of life can be achieved by:

o Enhancing physical well-being through effective symptom management: pain, nausea, vomiting, constipation, sleeplessness.

o Enhancing psychological well-being through management of anxiety, depression, fear, denial, hopelessness. Rather happiness, enjoyment, and leisure are promoted.

o Enhancing social well-being by addressing financial burden, caregiver burden, roles and relationships, affection and sexual function, and concerns about appearance.

o Enhancing spiritual well-being through minimization of suffering and instead focusing on religious beliefs, hope, and meaning.

Management and Nursing Interventions Provide pain relief, symptom control (air hunger, nausea, constipation, anxiety,

agitation), and prevention of complications. Encourage patient and family to exceed their current situation.

o Encourage patient and family to pursue enjoyable activities.o Assist patient and family to focus on present and past joys.o Share positive and hope-inspiring stories.

Facilitate participation in religious or spiritual activities. Encourage families to minimize social isolation. Provide private time for relationships. Discuss end-of-life issues early in patient's treatment plan. Encourage patients to express their preferences about end of life in the form of

a legal document.o Advance directives, such as a living will and durable power of attorney,

allow for the refusal of further treatment or authorize a family member or friend to make decisions for the patient (see page 194).

o After discussion with the patient and family, the primary care provider in an inpatient setting can write orders based on the directives such as “do not resuscitate.”

Make referrals for respite care, counseling, pastoral care, and bereavement services as needed.

Assist patients and families with decisions for withholding or withdrawing life-sustaining therapies and transfer in and out of inpatient settings by explaining such therapies and clarifying how they fit with the goals of care.

Promote ethical practice by organizing interdisciplinary rounds on patients with end-of-life care issues, setting up a partnership in care with family members, collaborating with other nurses who have been through similar situations, and consulting with the ethics committee within your institution.

NURSING ALERTIt is important for providers and nurses to have open and frank discussions with patients about their preferences regarding end-of-life care. This discussion should not occur during a life-threatening event when patients and families are stressed and feel rushed to make a decision.

Cancer Nursing

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